Regular outreach to patients who have frequent suicidal thoughts through a patient portal and referral for additional services may not be enough to reduce their risk of self-harm, suggests a report published this week in JAMA. The study also found that patients who were offered online brief dialectical therapy (DBT) skills training in additional to usual care had an increased risk for self-harm compared with those who received usual care only.
“These findings do not argue against systematic efforts to identify and address suicide risk in health care settings,” wrote Gregory Simon, M.D., M.P.H., of the Kaiser Permanente Washington Health Research Institute and colleagues. “Instead, they indicate that the low-intensity adaptations of care management and DBT skills training tested in this trial have no benefit over usual care in these health systems, especially when offered to the broad population reporting frequent suicidal ideation.”
Simon and colleagues used electronic health record (EHR) data from four health systems that provide insurance coverage, as well as mental and medical health care. The systems routinely administer the 9-item Patient Health Questionnaire (PHQ-9) at all mental health visits or primary care visits for depression treatment. The authors identified 18,882 patients aged 45 years or older who reported thoughts of death or self-harm for the majority of days during the past two weeks. Participants were excluded if they were not insured by the health systems, if they did not previously use the systems’ patient portals, if they had dementia or a developmental disability, or if they needed an interpreter.
Patients were randomly assigned to continue their usual care (access to mental health or general medical services) or to have their usual care supplemented with a care management intervention or an online DBT skills training. The interventions were offered for up to 12 months, and the primary outcome was the time to a nonfatal or fatal self-harm event.
Both interventions began with invitation messages from a study clinician through the EHR portal. The care management intervention included regular outreach for assessment of suicide risk using the Columbia Suicide Severity Rating Scale, followed by recommendations and encouragement regarding outpatient follow-up. The skills training included an interactive online program with videos demonstrating four skills based off DBT: mindfulness, mindfulness of current emotion, opposite action, and paced breathing. Skills coaches sent EHR portal messages to reinforce visits to the online program and encourage practicing specific skills.
Thirty-one percent of participants offered care management and 39% offered skills training accepted the invitations to the interventions. During the 18-month follow-up period, 540 participants experienced a self-harm event (45 fatal and 495 nonfatal events), including 172 (3.27%) offered care management, 206 (3.92%) offered skills training, and 162 (3.10%) in the control group. The risk of self-harm did not differ significantly between the care management and usual care groups but the risk of self-harm among those offered skills training was approximately 30% higher than in usual care.
In an accompanying editorial, Barbara Stanley, Ph.D., and Lisa Dixon, M.D., M.P.H., of the Columbia University Vagelos College of Physicians and Surgeons wrote, “[T]he study raises as many questions as it answers, underlining the importance of looking more deeply to understand what the findings of this trial may reveal.”
They continued, “Although the findings from this study do not support implementation of the programs as tested, it may be that the implementation strategy failed, rather than the therapeutic approaches from which their interventions were derived. … This study provides an important lesson for investigators, health care network administrators, and policy makers addressing the critical challenge of scalability in implementing and advancing efforts to identify patients with suicide risk and prevent self-harm.”
For related information, see the Psychiatric News article “Preventing Suicide Begins With Regular Assessments.”
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